Cardiac Exam fall |2024-2025
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A client is recovering from a myocardial infarction. Before developing the client's
teaching plan, it is important for the nurse to:
1. Identify the learning needs of the client
1
2. Determine the nursing goals for the client
3. Evaluate the community resources available to the client
4. Explore the use of group teaching for the client
A client in the emergency department is diagnosed with atrial fibrillation. Initially
the health care provider instructs the client to perform the Valsalva maneuver by
holding the breath and bearing down. What should the nurse include in an
explanation of how this may convert atrial fibrillation to a normal sinus rhythm?
Correct 1
Vagus nerve is stimulated.
2
Glottis closes momentarily.
3
Thoracic pressure decreases.
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4
Respiratory pattern is interrupted.
Inhaling and forcing the diaphragm and chest muscles against a closed glottis
increase intrathoracic pressure, which affects the vagus nerve and slows the heart.
Although the glottis closes, this does not interrupt the dysrhythmia. Thoracic
pressure increases, not decreases, during the Valsalva maneuver. Although the
respiratory pattern is interrupted briefly, this does not interrupt the dysrhythmia.
The client is in atrial fibrillation. The nurse is aware that atrial fibrillation results in:
Correct 1
A loss of atrial kick.
2
Decreased risk of pulmonary embolism.
3
Increased cardiac output.
4
No physiologic changes.
3
Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic
quivering of the atria and ineffectual atrial contraction. The atrioventricular (AV)
node is bombarded with hundreds of atrial impulses and conducts these impulses in
an unpredictable manner to the ventricles. This irregularity is called "irregularly
irregular." The ineffectual contraction of the atria results in loss of "atrial kick." If too
many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular
response may result and compromise cardiac output. One complication of atrial
fibrillation is thromboembolism. The blood that collects in the atria is agitated by
fibrillation, and normal clotting
A woman comes to the office of her health care provider, reporting shortness of
breath and epigastric distress that is not relieved by antacids. To what question
would a woman experiencing a myocardial infarction respond differently than a
man?
4
1. "Do you have chest pain?"
2. "Are you feeling anxious?"
3 "Do you have any palpitations?"
4. "Are you feeling short of breath?"
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Terms in this set (46)
A nurse is assessing The pedal pulse is located on the top of the foot
arterial perfusion in a and is the most distal peripheral pulse
client who had surgery
with placement of a graft
for an aneurysm in the
left femoral artery. Click
the site of the pulse that
should be assessed to
determine maximum
arterial perfusion distal to
the operative site.
The health care provider Answer
prescribes a progressive 2. Stop to rest until the pain resolves
exercise program that
includes walking for a Decreasing the demand for oxygen by resting will
client with a history of relieve the pain. Pain will not resolve as long as
diminished arterial exercise, thus muscle hypoxia, is continued,
perfusion to the lower regardless of whether ASA is taken. Walking more
extremities. The nurse slowly while pain is present is appropriate for
explains to the client that venous insufficiency, not arterial insufficiency.
if leg cramps occur while Sublingual nitroglycerin is not indicated for leg
walking, the client cramps
should:
1. Take one aspirin (ASA)
twice a day
2. Stop to rest until the
pain resolves
3. Walk more slowly while
pain is present
4. Take one nitroglycerin
tablet sublingually
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When a client is Answer
experiencing 3. Maintaining peripheral vasoconstriction
hypovolemic shock with
decreased tissue With shock, arteriolar vasoconstriction occurs,
perfusion, the nurse raising the total peripheral vascular resistance and
expects that the body shifting blood to the major organs. With shock, more
initially attempts to ADH is produced to promote fluid retention, which
compensate by: will elevate the blood pressure. Although producing
more red blood cells is a response to hypoxia,
1. Producing less peripheral vasoconstriction is a more effective
antidiuretic hormone compensatory mechanism. With shock the
(ADH) mineralocorticoids increase to promote fluid
2. Producing more red retention, which elevates the blood pressure
blood cells
3. Maintaining peripheral
vasoconstriction
4. Decreasing
mineralocorticoid
production
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